CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1985 2140.25 79189.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1731 1818.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 269 172.50 6346.50 36.79
TCM-T1017TL-TARGETED CASE MANAGEMENT 2938 25571.8 946117.75 37.00
Subtotal (Total Children Is Unduplicated) 2943 29702.5 1031653.50 34.73
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 4.00 194.00 48.50
EVAL-EVAL-DEVELOPMENTAL EVALUATION 227 229.25 11462.50 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 147 140.25 7012.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 51 41.00 3075.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 17.00 1275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 21 16.50 1237.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 151 208.00 15600.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 163 184.00 10212.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 386 298.50 22387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 18.50 1387.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 238 195.00 14625.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 996 1013.00 56221.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 778 890.50 66787.50 75.00
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.00 25.96 25.96
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 619 623.00 115205.50 184.92
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 16 16.00 4400.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 143 170.00 17850.00 105.00
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 11 11.00 1760.00 160.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 45 47.00 2279.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 65 69.00 3346.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 63 70.00 3395.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 27 30.00 1455.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 160 176.00 8536.00 48.50
Subtotal (Total Children Is Unduplicated) 1858 4468.50 369730.96 82.74
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 129 260.25 13012.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 10 6.00 150.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 187 697.50 34875.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 173 799.50 19987.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 71 223.00 11150.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 78 290.00 7250.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 24.50 1225.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 2.00 50.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 129 434.50 21725.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 125 509.00 12725.00 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 6.00 440.52 73.42
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 191 15013.0 375325.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 87 7577.00 189425.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 199.00 9950.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1026 17451.8 872387.50 49.99
OCCT-97530-OT SESSION BY LICENSED OT 188 1861.35 126119.69 67.76
OCCT-97530HM-OT SESSION BY OT ASST 10 17.00 923.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 176 1801.00 122158.60 67.83
PHY-97110HM-PT SESSION BY PT ASST 4 10.50 570.36 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 9 23.00 1150.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 1 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 271 2274.19 154069.73 67.75
SPL-92508-GROUP SPL SESSION PER CHILD 7 14.00 184.80 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1395 1565.00 10830.00 6.92
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 958 462628 231313.50 0.50
Subtotal (Total Children Is Unduplicated) 2023 513692 2217248.14 4.32
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Total 547863.04 3618632.60 6.60
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Number of Children (Unduplicated) With at Least One Service 2951
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Center 04
Flag Claims Units Chgs Paid
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R 33 41.25 1526.25 0.00
U 0 0.00 0.00 0.00
B 3460 3321.75 129703.25 0.00
P 25590 484252.56 1271173.75 1262448.74
D 1128 2896.75 67502.96 33258.29
S 0 0.00 0.00 0.00
H 3732 12163.73 619963.61 620927.91
T 0 0.00 0.00 0.00
27554 45187.00 1528762.78 0.00
Other 0 0.00 0.00 0.00
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Total 61497 547863.04 3618632.60 1916634.94